Functional Behavior Assessment/Progress Reportlacare.org/sites/default/files/PL0311-functional... · Progress Report Graphs: IX. SUMMARY OF OVERALL PROGRESS SUMMARY AND RECOMMENDATIONS

Member’s name

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Functional Behavior Assessment/Progress Report

I. IDENTIFYING INFORMATION

Patient’s Last/First Name:

Patient’s Date of Birth:

Patient’s age: FBA PR 1 PR 2 PR 3 PR 4 PR 5 PR 6

Patient’s Diagnosis:

Legal Guardian’s Name:

Legal Guardian’s Phone:

Home language:

Service Address:

Health Plan Name: L.A. Care Health Plan

Medical ID#:

PCP Name: FBA PR 1 PR 2 PR 3 PR 4 PR 5 PR 6

PCP’s phone number: FBA PR 1 PR 2 PR 3 PR 4 PR 5 PR 6

10 day timeline is met: (Y/N)

FBA PR 1 PR 2 PR 3 PR 4 PR 5 PR 6

Date of Report: FBA PR 1 PR 2 PR 3 PR 4 PR 5 PR 6

The Business Name of the Provider:


QAS Provider’s Name and Credentials:


Provider Contact Phone Number:


Percent of Session Cancelations by Parent:


Percent of Session Cancelations by Provider:


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II. REASON FOR REFERRAL

Source of referral Reason for referral

FBA

☐L.A. Care Health Plan

☐Legal Guardian

☐Other:

☐Other:

☐Identify behavior(s) of concern and establish baseline levels

☐Identify antecedent(s) and function(s) of behaviors of concern

☐Identify baseline repertoire in Verbal behaviors, Listener behaviors, Motor imitation, Scanning skills, Discrimination/MTS, Social and play skills, Daily living and Safety skills

☐Recommend evidence based behavior analytic treatments to address behaviors of concern and skill deficits

☐ Other:

PR 1

☐L.A. Care Health Plan

☐Legal Guardian

☐Other:

☐Other:

☐Report progress on current goals

☐Revise goals that have not been met:

☐Propose new goals

☐Revise current treatment plans

☐Propose New Treatment plans

☐Other:

III. BACKGROUND INFORMATION

A. Family structure

FBA PR 1 PR 2 PR 3 PR 4

Primary Care taker

Home language Number of people living in the household

Space to hold the sessions Level of environmental enrichment Recent changes in the household Department of Child and Family Services (DCFS) Involvement (if applicable)

Placement in foster/group home

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B. Caregiver and member availability (Time frame)


Monday

Tuesday

Wednesday

Thursday Friday

Saturday

Sunday

C. Physical and mental health history

FBA PR 1 PR 2 PR 3 PR 4 Medical or Physical Problems Allergies Gender Specific conditions that could impact treatment

History of hospitalizations and recent injures

Medications Vision and hearing issues Sleeping difficulties Food selectivity/refusal Swallowing food or liquids issues

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D. Current or prior home or outpatient services

Type of Service Number of Treatment Hours per Week

Dates of Service Provider

E. School history and current school based services


School Name School Start and End times

School District

Grade

Special Education Eligibility

Date of initial IEP (if available)

Current placement (please check the appropriate box) FBA PR 1 PR 2 PR 3 PR 4

• Fully included in a general education classroom • General education class with Resource Specialist Support • Special Day Program Class with inclusion in general education

classes

• Special Day Program Class with inclusion only during school wide activities

• Special Education Center • Non-Public School Placement (e.g., Help Group)

Parental concerns related to client’s behaviors and academic performance at school

FBA

PR 1

PR 2 PR 3

PR 4 If school observation is conducted, teacher concerns related to client’s behaviors and academic performance at school (FBA only) (School observation is optional)

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F. Special Education Related Services Provided at school ➢ For each type of school based service the client receives at the time of the report indicate the number of minutes/hours per week

FBA PR 1 PR 2 PR 3 PR 4 Language and Speech (LAS)

Occupational Therapy (OT) Adaptive Physical Education (APE)

Physical Therapy (PT)

Behavior Intervention Consultation (BIC)

Behavior Intervention Development (BID)

Behavior Intervention Implementation (BII)

Deaf and Hard of Hearing (DHH)

DIS Counseling (Counseling provided by the school psychologist)

Mental Health Counseling

Assistive Technology (AT)

Audiology (AUD) Orientation and Mobility (O and M)

Orthopedic Impairment Itinerant (OI)

Recreational Therapy (RT)

Visual Impairment Itinerant (VI)

Other:

G. Care Coordination Involving the Parents or Caregiver(s), School, State Disability Programs and Others as Applicable

FBA

PR1

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IV. CLINICAL INTERVIEW

A. Parental concerns and priorities

Problem behaviors Clinical rational if not addressed during current

reporting period

Skill Deficits Clinical rational if not addressed during current

reporting period

FBA

PR1

V. DIRECT ASSESSMENT PROCEDURES/PROGRESS MONITORING RESULTS

A. Data collection methods

Dates of data collection Data Collection Method(s) Location of data collection Person(s) collecting data and credentials

FBA

PR 1

VI. PREFERENCE ASSESSMENT (PA)

Date of most recent PA

Type of PA List of most preferred stimuli

FBA ☐Survey/caregiver interview

☐Paired choice

☐Single Stimulus

☐MSWO

☐Free Operant Engagement Based

PR 1 ☐Paired choice

☐Single Stimulus

☐MSWO

☐Free Operant Engagement Based

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VII. OUTCOME MEASUREMENT OF RECENT ASSESSMENT CRITERIA. Insert Test Tables and Visual Representation of Client Profile below (e.g.,

VB-MAPP, Vineland, AFFLS, etc.)

VIII. IDENTIFY MEASURABLE GOALS AND OBJECTIVES THAT ARE SPECIFIC, BEHAVIORALLY DEFINED, DEVELOPMENTALLY APPROPRIATE, SOCIALLY

SIGNIFICANT AND BASED ON CLINICAL OBSERVATION

A. Domain: Communication (e.g., Manding for items/actions/information, Tacting (objects, actions, feelings, emotions), Echoics,

Receptive identification for objects, Receptive identification for actions, Intraverbal behavior)

Target Behavior

FBA

Objective baseline level of performance (per goal) based on assessment criteria and clinical observation

Relative strengths: Skill Deficits:

Individualized measurable goal(s) with estimated date of mastery

Generalization criteria Treatment Plan to address the initial goal(s) Evidence based BHT services with demonstrated clinical efficacy

PR 1

Goal 1 Met : ☐Yes ☐ No



Present level of performance (PLP) based on assessment criteria and clinical observation

List the environmental barriers that hindered

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Generality Criteria for : Goal 1 Met : ☐Yes ☐ No



meeting the goal and solution:

Revised or New Individualized measurable goal(s) with estimated date of mastery. Evidence based BHT services with demonstrated clinical efficacy.

Generalization criteria Treatment plan to address the revised or new goal(s). Evidence based BHT services with demonstrated clinical efficacy.

➢ Progress Report Graphs:

B. Domain: Skills required for learning (e.g., behavior Cusps/prerequisite skills such as motor imitation, eye contact,

MTS, attending skills)

Target Behavior

FBA

Baseline level of performance (per goal) based on assessment criteria and clinical observation

Relative strengths: Skill Deficits:


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Generalization criteria Treatment Plan to address the initial goal(s) Evidence based BHT services with demonstrated clinical efficacy

PR 1








List the environmental barriers that hindered meeting the goal and solution:

Revised or New Individualized measurable goal(s) with estimated date of mastery

Generalization criteria Treatment plan (intervention) to address the revised or new goal. Evidence based BHT services with demonstrated clinical efficacy.


Member’s name

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C. Domain: Daily living Skills

Target Behavior

FBA


Relative strengths Skill Deficits:


Generalization criteria Treatment Plan to address the initial goal(s). Evidence based BHT services with demonstrated clinical efficacy /s

PR 1








List the environmental barriers that hindered meeting the goal and solution:


Generalization criteria

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Treatment plan (intervention) to address the revised or new goal


D. Domain: Community, Independent and Social Play and Social Interaction Skills

Target Behavior

FBA


Relative strengths Skill Deficits:


Generalization criteria Treatment Plan to address the initial goal(s). Evidence based BHT services with demonstrated clinical efficacy /s

PR 1




Generality Criteria for :


List the environmental barriers that hindered meeting the goal:

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Generalization criteria Treatment plan (intervention) to address the revised or new goal


E. PRESENT LEVELS OF PERFORMANCE FOR PROBLEM BEHAVIORS

• Complete one table for each problem behavior unless problem behaviors are part of a response class hierarchy

• If you are addressing multiple problem behaviors, copy and paste the problem behavior table and complete the information in

the table

Target Problem Behavior

Operational Definition

Baseline level (collected by

clinician, include a baseline

graph)

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Antecedents that are correlated

with the problem behavior(s)

Utilize evidence-based BHT

services with demonstrated

clinical efficacy in treating ASD

to identify the function(s) of

behavior (FA or conditional

probability results)

FBA

Individualized and

Measurable Behavior

Reduction Goal(s) with

estimated date of

mastery. Evidence based

BHT services with

demonstrated clinical

efficacy.

Individualized and

Measurable Alternative

Behavior Goal(s) with

estimated date of

mastery.


Initial Treatment Plan

(function based and

technological) to address

problem behavior(s).

Evidence based BHT

services with

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➢ BASELINE and Progress Report Graphs:

F. PARENT/GUARDIAN TRAINING

Support and participation needed to achieve the goals and objectives for both member and guardian


efficacy.

PR 1

Behavior Reduction

Goal Met: ☐Yes ☐No Alternative Behavior

Goal Met: ☐Yes ☐No Generality Criteria:

Behavior reduction:

Met: ☐Yes ☐No

Alternative Behavior

Present level of performance

(PLP) based on assessment

criteria and clinical

observation

Environmental barriers that hindered


Revised or New

Individualized

measurable goal(s) with

estimated date of

mastery

Met: ☐Yes ☐No


Treatment plan to

address the revised or

new goal(s). Evidence

based BHT services with


efficacy.

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FBA

PR 1

Guardian Training:

Target skill to be performed by

guardian(s)

Baseline level of performance

based on clinical observation

FBA

Individualized and

measurable guardian

goal(s) with estimated

date of mastery.


Treatment plan to teach

the skill identified in the

goal. Evidence based BHT

services with


efficacy.

PR 1




Generality Criteria for :



Present level of performance

(PLP) based on clinical

observation and

measurement

Environmental barriers that hindered


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IX. SUMMARY OF OVERALL PROGRESS

SUMMARY AND RECOMMENDATIONS

PR 1 PR 2 PR 3 PR 4 How many goals have been met in the last reporting period

How many goals have not been met and had to be modified

How many goals have been placed on hold because a member lacked a prerequisite skill How many goals will be targeted during the next reporting period

CLINICAL RATIONALE FOR MODIFICATION OF HOURS

CRISIS PLAN

TRANSITION PLAN

DISCHARGE CRITERIA


Revised or New individualized and measurable goal(s) with estimated date of mastery.


Treatment plan to address the revised or

new goal(s). Evidence based BHT

services with demonstrated clinical

efficacy.

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Note: Please include the following disclaimer in your reports: The content of this report has been thoroughly discussed with client’s parent(s). Parent(s) agree with

assessment findings, intervention plans, goals, objectives and recommendation. If parents do not agree with any part of your report indicate which parts and the reason for

disagreement.

Signature of Qualified Autism Service Provider Credentials of Qualified Autism Service Provider Date

Documents

Functional Behavior Assessment/Progress Reportlacare.org/sites/default/files/PL0311-functional... · Progress Report Graphs: IX. SUMMARY OF OVERALL PROGRESS SUMMARY AND RECOMMENDATIONS